Other·December 17, 2021

F684 §483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices.

F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §72311 - Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. § 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 9/22/21, the Department received a complaint regarding a resident (Resident 1) who had an abdominal ultrasound done but no one to interpret the results, was transferred to a General Acute Care Hospital (GACH) where he died two days later. On 9/23/21, an unannounced investigation was conducted at the facility. The facility failed to ensure: 1. Licensed nurses (LVN 1 and LVN 2) did not write a second abdominal ultrasound order. 2. LVN 1 and LVN 2 did not carry out the physician’s (MD 2) orders without the MD 1’s knowledge when Resident 1 had a change of condition. 3. LVN 1 and LVN 2 notified Resident 1’s attending physician (MD 1) of abdominal ultrasound results in a timely manner in accordance with the facility’s policies and procedures. As a result of Resident 1’s delayed transfer to a GACH, the resident was diagnosed with Sepsis (body's life-threatening response to infection that can lead to tissue damage, organ failure, and death) and acute Cholecystitis (inflammation of the gallbladder), and then underwent laparoscopic abdominal surgery and died. A review of Resident 1' admission record indicated the resident was initially admitted to the facility on 9/11/21, with diagnoses including nephrolithiasis (kidney stones, hard deposits made of minerals and salts that form inside your kidneys), stroke (blood flow to your brain stops and brain cells start to die) with right-sided hemiparesis (a mild or partial weakness or loss of strength on one side of the body) and aphasia (loss of ability to understand or express speech, caused by brain damage). A review of Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment tool, and care-screening tool) dated 9/14/21 indicated the resident had intact cognitive response and able to make needs known. A review of Situation-Background-Assessment-Recommendation-form (SBAR) dated 9/13/21 at 11:15 p.m., Resident 1 complained of right lower side abdominal pain. A review of the SBAR indicated there was no documented pain evaluation, no change in level of consciousness, no respiratory distress, vital signs stable with blood pressure of 140/90, pulse of 78, respiration rate of 18, temperature of 98.0, pulse oximetry of 98% on room air. A review of a document titled “Physician’s Telephone Order” dated 09/14/21, at 6:15 a.m. indicated there was an order for abdominal ultrasound ([US] an imaging test that uses sound waves to create a picture) due to Resident 1’s complaint of abdominal pain. A review of US result dated 9/14/21 at 11:30 am indicated Resident 1 had Cholecystitis [the presence of gallstones in the gallbladder (a pouch the size of a lime that sits under the liver and stores bile which produced by the liver and helps with digestion of fat)] and adenomyomatosis [benign condition that can present with right upper quadrant pain and characterized by hyperplasia (the enlargement of an organ or tissue caused by an increase in the reproduction rate of its cells)] of the gallbladder wall mucosa (moist tissue that lines certain parts of the inside of your body). A review of the licensed nurse's notes dated 9/14/21 at 2:00 p.m., indicated LVN 1 received the first ultrasound result and relayed the result to a urologist, ([MD 2] a physician who diagnoses and treats diseases of the urinary tract) ordered Stat CBC (urgent or rush complete blood count). LVN 1 documented MD 2’s verbal order for the MD 1 to sign. During an interview with the Director of Nursing (DON) on 9/23/21 at 11:55 a.m. DON stated two ultrasounds were ordered for Resident 1. DON stated, "first ultrasound was ordered on 9/14/21 at 6:15 a.m., the second ultrasound, I am not sure when it was ordered”. DON stated Resident 1’s family (FM 1) asked for a second interpretation of the first ultrasound result to make sure the resident was bleeding. DON stated FM 1 was concerned because the facility re-started Eliquis (medicine used to reduce the risk of stroke and blood clots) and Aspirin (blood thinner) that was held by MD 2 before Resident 1 was transferred to the facility. DON stated FM 1 pressured the nurses to get a second interpretation of the ultrasound results. During an interview on 10/1/21 at 12:37 p.m., LVN 1 stated on 9/14/21 at 2:00 p.m., she notified MD 2, who was not affiliated with the facility, of Resident 1’s ultrasound results instead of MD 1, who was the Resident 1’s attending physician. LVN 1 stated the Urologist ordered a Stat CBC for Resident 1. LVN 1 also stated she was aware of the facility’s policy to notify the resident’s attending physician first of Resident 1’s results but she did not have time to notify MD 1. LVN 1 added that she should have contacted MD 1 first per the facility’s policy and procedures on physician notification. During a concurrent interview and record review on 10/1/21 at 1:15 p.m., LVN 2 stated LVN 1 reported to follow up on the result of Resident 1’s abdominal ultrasound during shift change around 3:00 p.m. LVN 2 stated on 9/14/21 at 10:00 p.m., she called the facility’s diagnostic laboratory (lab) to request for a second interpretation of the first ultrasound but did not get any because the lab staff were busy and promised to call her back. LVN 2 stated MD 1 must be informed of the test results first, then a medical director if the attending physician was unavailable and then the physician on-call. LVN 2 stated she did not speak with Resident 1’s attending doctor regarding the ultrasound results during her shift. During a telephone interview on 10/4/21 at 9:58 a.m., the facility’s lab representative (LP 1) stated Resident 1’s ultrasound dated 9/14/21 was completed on 9/14/21 at 10:50 a.m. and faxed to the facility. LP 1 stated the second interpretation of the same ultrasound result (first ultrasound) was completed on 9/14/21 at 7:41 p.m. and re-faxed to the facility. LP 1 stated the request reason written on the “Requisition Order” indicated “to rule out bleeding- definitive answer regarding interpretation to continue medication" (pertaining to Eliquis and Aspirin) as requested by LVN 2. During a phone interview on 10/7/21 at 2:20 p.m., LVN 2 stated she spoke with MD 1 and ordered another abdominal ultrasound on 9/14/21 at 10:55 p.m. When LVN 2 was asked if she read the result of the first ultrasound to Resident 1’s attending physician, she did not answer. LVN 2 stated the urologist and FM 1 wanted another ultrasound because the first ultrasound was not clear. LVN 2 stated she called the lab on 9/14/21 at 10:50 p.m. because she could not find the second interpretation. LVN 2 did not mention about the CBC result reported to the attending physician. A review of Resident 1’s Physician's telephone order dated 9/14/21 at 10:55 p.m. indicated abdominal ultrasound to rule out bleeding and was signed by LVN 2 on 9/15/21. During a phone interview on 10/7/21 at 2:50 p.m., Resident 1’s attending Physician (MD 1) stated he did not order CBC and could not remember what date and time he received the CBC and ultrasound results. Resident 1’s attending Physician stated, "I never ordered another ultrasound, it does not make sense. There was no reason to order another ultrasound.” MD 1 stated the resident’s transfer was ordered right away based on the first ultrasound result the facility notified him of on 9/15/21 at 7:00 p.m. MD 1 stated he was not aware LVN 1 wrote a physician telephone order for CBC using his name. MD 1 stated if another MD 2 recommended a CBC blood test, LVN should have written the MD 2’s name, on the order and asked MD 2 to sign the order. MD 1 stated LVN 1 did not notify MD 1 about the telephone orders. During a phone interview on 10/7/2021 at 2:58 p.m., DON verbalized LVN 1 should have written MD 2’s name for MD 1 to co-sign the order. During a phone interview on 10/7/21 at 4:54 p.m., Registered Nurse (RN 2) stated on 9/15/21 at 6:00 p.m., she noticed Resident 1’s first abdominal ultrasound result was "flagged" (tabbed for quick reference), RN 2 did not know who flagged the ultrasound result in the chart but paged MD 1 right away because it was priority to notify him. RN 2 stated she was not sure if MD 1 already knew the result of Resident 1’s first abdominal ultrasound. RN 2 informed MD 1 that Resident 1 did not look comfortable and was complaining of pain on the right lower side of the abdomen. RN 2 stated she immediately notified FM 1 after MD 1 ordered Resident 1’s immediate transfer to the hospital on 9/15/21 at 19:20 p.m. A review of the Licensed Nurses notes dated 9/15/21 at 7:00 p.m. indicated RN 2 paged MD 1 and reported abnormal abdominal ultrasound results indicative of Cholelithiasis of the gallbladder (the presence of one or more calculi [(gallstones) in the gallbladder] and of elevated white blood cells count (WBC, help body to fight infection) from the CBC test results. The licensed nurses note also indicated on 9/15/21, at 7:20 p.m., RN 2 notified MD 1 that Resident 1 was complaining of abdominal pain on a right lower abdominal pain and the resident was transferred to a GACH on 9/15/21 at 9:30 p.m. via ambulance. A review CBC test result, ordered on 9/14/21 at 2:00 p.m., and reported at 8:53 p.m. indicated Resident 1 had a high level of WBC of 13.7 K/mm3 (thousand cells per cubic millimeter (mm3) -a unit of cell concentration expressed as a number of cells in thousands per unit volume equal to one cubic millimeter. Normal range 4.8- 10.8 K/mm3. resulted on 9/14/21 at 8:53 p.m. During a phone interview on 10/12/21 at 11:58 a.m., MD 1 stated DON told MD 1, the staff ordered another abdominal ultrasound because the first ultrasound was preliminary, and no radiologist was available to read the final report. MD 1 stated the nurses did not notify him of Resident 1’s first ultrasound result. MD 1 also stated the nurse (LVN 2) ordered another ultrasound without his knowledge and that he was not going to sign the order because it was written without his permission. MD 1 added that it was unnecessary to order a second ultrasound for Resident 1. A review of Resident 1’s GACH Emergency Room (ER) medical record dated 9/15/21, at 10:30p.m., indicated the resident’s WBC result was 19.6K/mm3. A review of Resident 1’s GACH Critical Care Note dated 9/16/21, indicated the resident had Leukocytosis (a condition that causes body to have too many white blood cells), Sepsis, and acute Cholecystitis, a diffuse tenderness to the right upper quadrant of the abdomen, tenderness with and pain that required immediate evaluation. A review of Resident 1’s nurses progress note dated 9/16/21indicated Resident 1 was admitted to GACH medical unit and started on Ancef antibiotic (medications that destroy or slow down the growth of bacteria). A review of Resident 1’s GACH Discharge Summary dated 09/20/21 indicated on 9/17/21, Resident 1 underwent a Laparoscopic Cholecystectomy (minimally invasive surgery to remove the gallbladder). A review of Resident 1’s death certificate indicated Resident 1’s immediate cause of death was cardiorespiratory failure (abrupt loss of heart function, breathing and consciousness) and other contributing causes included acute cholecystitis, in which a laparoscopic cholecystectomy on 9/16/21. A review of Resident 1’s GACH Pathology report dated 9/17/21 indicated Resident 1 was diagnosed with the Purulent (containing pus) Peri-cholecystitis (inflammation of tissues situated around gallbladder) associated with gangrenous (death of tissue) mural necrosis (submucosa wall death) and perforation (a hole that develops through the wall of a body organ) (complicated advanced subtype of acute Cholecystitis associated with high death rate). A review of the facility's undated Job Description for LVNs indicated, LVNs provided care and treatment in accordance with physicians’ orders. The job description indicated LVNs worked under the direction of physicians and registered nurses. The job description indicated LVNS’ essential duties and responsibilities include the following: 1. Assess residents by physical examination, including pertinent diagnostic testing to determine test results. 2. Communicate with physicians regarding changes in residents’ conditions, and diagnostic test results. 3. Document residents’ assessments and care in compliance with standards of care and company policy. A review of the facility’s policy titled “Physician Orders” revised on 8/21/20 indicated Physician orders will include name of the ordering provider, resident’s name, the date, and time the order was received, and the signature of the licensed nurse receiving and documenting the order (if taken by telephone). A review of the facility's policy and procedure titled "Change of Condition Notification" revised on April 01, 2015 indicated: 1. "Change of Condition" related to Attending Physician notification is defined as when the Attending Physician